1
www.KneeWalkerCentral.com Letter of Medical Necessity/Rx Knee Walker HCPC Code: #E0118 - Crutch Substitute, with or without wheels To be completed by physician, health care provider, or medical facility Patients Full Name : __________________________________________________________________________________________________ Date Needed : _____________________________ Expected Duration of Rental : ________________________________________ Diagnosis :_____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Side of Injury: Left Right Date of injury (if applicable): ________________________ Date of surgery (if applicable): ________________________ Code : ______________________ Code : ______________________ Code : ______________________ Code : ______________________ Code : ______________________ Code : ______________________ Signature / Date: ______________________________________________________________________________________________________ Printed Name / NPI #: __________________________________________________________________________________________________ Phone Number: _________________________________________ (check one) Patient has fracture dislocation tendon rupture surgery which requires absolute non-weight bearing to maximize chances for optimal healing and recovery. This patient is unable to utilize crutches effectively, or is unable to perform tasks of daily living with crutches. Patient has an ulcer infection which requires absolute non-weight bearing to maximize chances for optimal healing and recovery. This patient is unable to utilize crutches effectively, or is unable to perform tasks of daily living with crutches. Patient has a neurologic musculoskeletal condition which makes him/her unable to effectively, or safely bear weight on one foot. the rolling knee scooter will greatly increase this person’s ability to function independently. Other: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________
